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Wisconsin De#;~rtment of Commerce PRIVATE SEWAGE SYSTEM
Safetz~sd iiui~riings Division
77 INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provice may be used for secondary purposes [Privacy Laws s.15.04 (1)(m)).
Permit Nolder's Name: ^ City ^ V Ila a _~ wn of:
McCabe Homes Inc., I~uc~son~ownship
CST BM Elev.: Insp. BM Elev.: BM Description: ~~,ff,~,,~,,~,
TANK INFORMATION
TYPE MANUFACTURER CAPACITY
Septic
Dosing G~~
Aeration V
Holding
TANK SETBACK INFORMATION
TANK TO P/ L WELL BLDG. vent to
Airlntake ROAD
Septic NA
Dosing NA
Aeration NA
Holdin
g
PUMP / I
Ma facturer
odel Number
DH Lift 9~
INFORMATION
~riction Svst
Fo Ain Length
SAIL ABS
Dia.
SYSTEM
Demand
GPM
•'m TDH Ft
Dist. To Well
ELEVATION DATA
coun5t Croix
Sanit~ry3grrrjt No.:
State Pttlffanl ~JtD No.:
Parcel Tax No.:
020-1376-42-000
STATION BS HI FS ELEV.
Benchmark ,Sp ~p3,$Of X60.0/
Alt. BM
Bldg. Sewer "" ? ''
St/Ht Inlet rZ.Z ,~ 9~ ~S~
St / Ht Outlet - ._ -~^
Dt Inlet ------
Dt Bottom (S'3a ~ ~ ~
Header /Man. 9.3
Dist. Pipe ~,~ qS, 3S ~
Bot. System ^~ -'g ~, $ cf , q S''
Fi Grade ~j .gyp , 30
~ ) CI ~ ~
Ong i~ n //
BED /TRENCH V ~. - V
Width / Len t / No. Of Trenches
PIT
No. Of P'
Inside Dia. Liquid Depth
I N I N 3 DIM I N
SYSTEM TO P/ L BLDG WELL
LAKE /STREAM LEACHIN Manu adurer:
_ /Q ~ ~`
SETBACK
INFORMATION Type O ~,y~ y CHAMBE Mo a Num er:
System: + OR U
IIISTRIRI ITICIN SYSTEM
He /Maui of Distri ution Pipe(s) x Hole Size I x Hole Spacing I Vent To Air Intake
~
Length Dia. ~
Length Dia. Spacing ~~ ~
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over (,~
/ Depth Over xx Depth Of xx Seeded /Sodded xx Mulched
Bed /Trench Center
~ Bed /Trench Edges Topsoil ^ Yes No Yes ^ No
~~
/ COMMENTS: (Include code discrepancies, persons present, etc.) OS~o/ moo/ ~~~ ~//0/O~
Location: 960 Florence Lane, Hudson, WI 54016 (SW 1/4 N 1/414 T29N R19W) - 1429192303 Sweet
Grass Farm -Lot 42 ~ ~~~. ~~~1/h ~~~0/
1.) Alt BM Description = ~ , ~, w
2.) Bldg sewer length = ~~/~~~t-d G~t ~2~ 7"''~
-amount of cover = ~~ ' 7
Plan revision required? Yes ^ No
Use other side for additional information.
SBD-6710 (R.3/97) Date Inspector's Signature Cert. No.
..e
~ 9'~ a ~l .oQ1~1c~. ~ 1 E
~l~¢t . ~7 3.~ ~
-Sanitary Permit Application Safety & Bui4dings D
In accord with Comm 83.21, Wis. Adm. Code 201 W. Washingto
i See reverse side for instructions for completing this application PO Bo
seonsin
Department of Commerce Personal information you provide may be used for secondary purposes Madison. WI 5370
(Submit Completed form to count
(Privacy Law, s. f 5.44(I)(m)}
state o
Attach coin lete laps (to the count co onl )for the s n" a er not less than 8-1/2 x t 1 inches in size.
Coun~ ~ Stal S i~t
a~Pe it Number ^ Ch ~r vi i n to previous application State Plan I. D. Number
J
I. A lication Information -Please Print all Information O Location:
Properly Owner Name ~, .,.. _ Properly Location
1 ~' Q
.SGT t!4 Nwll4, S T Q~ I,N, R
Property Owner's Mailing Address - - _ Lot Number Block Nu
3 - ~ ST CROIX
`
~~
/
+ COUNT
Ciry, State Zip Code ned'~INItlIfd ,- ` `
' ~. Subdivision Name or CSM Number
~
~
~ ~ 5~
ll Type of Building: (check one) / ^ City
I or 2 Family Dwelling - No. of Bedrooms:_~ ^ village
Town of
Public/Commercial (describe use): ~
O State-owned C~
~
III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest ad
A) I . New System 2. ^ Replacement 3. ^ Replacement of 4. O Addition to Parccl Tax Number(s)
S stem Tank Onl Existin S stem - d(
B) Permit Number Date Issued
^ A Sanita Permit was reviousl issued f ~ O
! Type of POWT System: (Check all that apply)
Non-pressurized ln-ground ^ Mound ^ Sand Filter ^ Constructed Wetland
^ Pressurized !n-ground ^ Holding Tank ^ Single Pass O Drip Line
^ At-grade ~ ^ Aerobic Treat ent nit ^ Recircul ing ^ Other:
V Dis ersaUTreatment Area Information: Qp
I Design Flow (gpd) 2. DispersalArea 3. Dispersal Arca 4. Soil Application 5. Percolation Rate 6. Syst do 7. Final Gra
Required Proposed ~ Rate (Gals./daylsq. ft.) (Min./inch) Elevation
(04 s o s ~, s-s-y -
VI Tank Capacity in Total k of Manufacturer Prefab Sit Steel fiber- Plast
lnformation Gallons Gallons Tanks Con- Con- glass
New Existing Crete strutted
Tanks Tanks
^ ^ ^ ^
S la -- o / ~
^ ^ ^ a ^
VII Responsibility Statement
1, the undersi ned, assume res onsibilit for installation of the POWTS shown on the attached tans.
Plumber's Name (print) Plumber' Signa re (n s amp MPRS No. Business Phone Number
Plumber's Address (Street, City, State, Zip Code
VIII CountyylDepartment Use Only
O Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued ssuing Agent Si azure (No stain{
i~Approved ^ Owner Given Initial Adverse Surc rge Fee) ~-
~~
~~ ~~ ~
Determination
IX. Conditions of Approval /Reasons for Disapproval: I ~J/~ _ I
.~ r. ~ rwuSt'1oR- J~-~ ~ 5 ~ 5-~, tl~ S~dx • ~ o~_ rt,9'•
} CS'r' ~S-E-re-,e.5`~-~~ t~.>'n C,o+r~res t~~ S,a t ~ r~' '~~ t S ~~~ ~,~ c~sC.
-~ ( t~b„e~~u.7t5, t+vta.t9~~ ~-6u~tt~_ ~--W . L . o~o..~ ~'3 0 . a ' ~ ~ P.°~
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1~3fsconsiri•Department of Commerce SOIL AND SITE EVALUATION ~
Division of nd Buildings Page of
Bureau of Int gy~ted Services in accordance with Comm 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must """"`r
include, but not limited to: vertical and horizontal reference point (BM), direction and ~ ~ • C t~U 1 `
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION -Please prin ~l ~cir-na!>hgn,''`~. Re iewed b~ Date
Personal information you provide maybe used for secondaitrposes (Privy Law, s. 15.04 ('F) (m)). ~ ~ ~ '~
Property Owner Property Location
c ~ Govt. qot Spy 1/4,uw 1/4,S ~ c ~ TZ ~ ,N,R ~q E (or~l
lC' ` ~~
Property Owner's Mailing Address l - `' ~ s ~, ,; Lot # - ~ Block# Subd. Name or CSM#
City State Zip Code a Phone Numbbr Nearest Road
;: ,~; ^~~ity ^ Village ®Town
d5a 1 0~~ (-~tt ~ ~`=t~~3- •f u ~ .~ --~ •Flor~-r1 ~ ~ ~.
~~ . ,
®New Construction Use: ®Residential /Number orris ~ ~ Addition to existing building
^ Replacement ^ Public or commercial -Describe:
Code derived daily flow ~'~-- gpd Recommended design loading rate bed, gpdffi2~trench, gpd/it2
Absorption area required bed, ft2 ~ S~ trench, tt2 Maximum design loading rate ' ~ bed, gpd/fiz ' ~ trench, gpd/ft2
Recommended infiltration surface elevati~o/n(s) ` Ste. ~ ~-~ ft (as referred to site plan benchmark)
Additional design/site considerations i~L '~' • ~ 5 ' S O
Parent material VU•f-c~Sl~i Flood plain elevation, if applicable tt
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
u = Unsuitable for system ®s ^ u ®s ^ u ®s ^ u [,~ s ^ u ^ s ®u ^ s ® u
CAII IIFSCRIPTIAN REP(]RT rile.- ~ I s.IIA ~,T, ~, ~ ~~ i (~•~~- ~
Boring #
~`
Ground
elev.
ft.
Depth to
limiting
factor
~._in.
Boring #
Z
Ground
elev.
Q4.5`~1 ft.
Depth to
limiting
factor
/ /L, in- Remarks_
;ST Name (Please Print) Signa Telephone No.
~ _/ ~ Lt,~..M. ct ~. e r^ ter,.-c- ~i ~ ` z `~/ 7-`/00 ~
Y~~r--m
'address Date CST Number
z ~ ~ ~-G ~- S~• ~p ~e / ~ f L.i 1 SG/o ~S ~i' -~/-aU 2 s-3 3 a
Horizon Depth Dominant Color Mottles Structure i B
d t
R GPD/ft2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. stence
Cons oun
ary oo
s Bed ,Trench
I o1s 1d r 3 ~ --_ S. J ~ ~. m ~ )v~ . Z ~ - 3
3 ~„ ID fY).5 r7 ~ ~ ~ ~ - • ~ ~ - ~
s . 6 ~r -t~ 3.qS~ ~.( ~ `' its b~''
Remarks:
PROPERTY OWNER ~ ~~~ SOIL DESCRIPTION REPORT
PARCEL I.D.# /(/
Boring #
~-
Ground
elev.
9q~tt.
Depth to
limiting
factor
flZ in.
Boring #
y
Ground
elev.
i ~•o - ft.
Depth to
limiting
factor
lain.
Boring #
5'
i
Gr~d
elev.
(o'f` ft.
Depth to
limiting
fact~r
~~in.
Boring #
Ground
elev.
n.
v
.~.
' Pa Af 3
Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench
I o-i3 ~~ z s ~ .~k. ~ ~> lv~ . z~- 3
2 ~3- ( ~il~ -- 5~ ~ m~b~ s - •s~~ ~
3 B-ilz I~ r y1 rns ds ~ ~5 - - ~ ; .~
Remarks:
a-+~- ~ Z ---- ~~
l 1 mQbk- -f-~ c S 1 v-~ .Z '
~ -y-3 yiy 5.1 Z ~ mf ~ -- ~ ,
3 - I 1 -~ as m! ~ `' ~ ~ -F~
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/tt2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
Z ~~ 37 4~ ~" I ,nn~o(~ SFr c s -' • s
I ~l lp ---~ m -'Yl ! ~ s -- - ~ ~ - g
Depth to Q
limiting
factor
'n' Remarks:
Remarks:
SBD-8330 (R.9/98)
,r
` x~ . '
PAGE~OF~
NAME ~fOU-I- LOT#,~Z LEGAL DESCRiPTION,SW'/ }/4 S/~ TIC/ N R/Q E (or~V
SCALE: I"=
BM I ELEVATION (~~ d
1
BM I DESCRIPTION a~ 2 "P~c a~ ~ lu-t-h ~..~/ r-~. ~ ~
BM 2 ELEVATION 9 Y, ~ a
~~
BM 2 DESCRIPTION~„p vSZ`~~dL ~(Jep,~(u-~'I, ~,~N/~
SYSTEM ELEVATION / 7 • s
ALTERNATE ELEVATION ~ ~~ Sd
CONTOUR ELEVATION /(//j~4
z
~. ~,S '
v ~~
~r
V
L
I ~
.-. _ _ 0 ~-~ + Z ~
1l :M
~~~tAw~ LO ~ 1. i ~!`: &" .- -~ z
W~~ V~lov Zc~ ~=~e-(_
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer /176Li~' ~~~~. ~/~ ;
Mailing Address
Property
8~~ ~Ln~~/ ~~
r/ ,5~8'Z.
Address ~ ~~ ~' ~~~ '~~ ,
(Verification required from Planning Department for new construction)
City/State ~U/~,/ ~~ Pazcel Identification Number
LEGAL DESCRII'TION
property Location ,.~~. %, .~~ 1/s, Sec. ~, T~N-R / / W, Town of ,~[.u~
Subdivision , .SZ~. PS~~°~? Lot # ~
Certified Survey Map # ~ .Volume ..Page #
Warranty Deed # ~ ~ 3 ~ q ,Volume ~ ~ Z(p .Page # ~ e S~
Spec house,~yes ^ no
Lot lines identifiablyyes ^ no
SYSTEM MAINTENANCE
Improper use and maintenaareof your septic system could resultin its prematurefailure to handle wastes. propermaintenance
consists of pumping out the septic teak every three years or sooner, if needed by a licensed pumper- What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification foam, signed by the owner and by a
master plumber; journeyman plumber, restricted plumber or a licensodpumper verifying that (1) the on site wastcwaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin, Certification
stating that your septic system been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of th year a oa date.
i/7/D/
SI ATURE O APPLICANT DATE
OWNER CERTIFICATION
1(we) certify that all s tements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the grope escn'bed abo y virtue of a warranty deed recorded in Register of Deeds Office.
y ~~ ~~ o/
SI ATURE OF APPLICANT DATE
****** rmit being revoked b the Zo ' De artment. ******
. Any information that is mis-represented may result in the sanitary pe Y ~g p
'~* Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the wauanty decd
1 r
Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In-Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWYS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In-Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
Table 1: System Design Specifications
Sanitary Permit Number
Number of Bedrooms --
Design Flow -Peak (gpd} ~ d~
Estimated Flow -Average (gpd)
Septic Tank Capacity (gal) , C
Soil Absorption Component Size (ftz) - ~ S -lam
Type of Wastewater Domestic
Table 2: Soil Absorption Component -Limits of Reliable Operation
~,
Septic Tank Component Soil Absorption Component
Design Flow -Peak (gpd) ~ CMG
Maximum Influent Particle Size (in) 1/8
Maximum BODS (mg/L) 220
Maximum TSS (mg/L) 150
Tab le 3: Maintenance Schedule
Septic Tank Inspect and/or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s: 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure
proper operation. The filter cartridge should not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
`~ ~ ,Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8-inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other Treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank maybe difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
.1
'. ~ Management Plan for a Septic Tank and Soil Absorption Component
Plantings of deep-rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
~~
3
. ~ i
' , ` STATE BAR OF WISCONSIN FORM 2 - 1998
' WARRANTY DEED
Document Number ~, Y O ~. ,~ V ~ ~ PA G E 3 05
This Deed, made between
RICHARD O_ STOUT and JANET P STOUT,
~~ husband and wife,
Grantor,
I'' and
/7~G~c~E DmEs C. ,,,-.
Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate in St _ Croix County, Slate of Wisconsin:
Lot 42, Plat of Sweet Grass Farm, Town of
Hudson, St. Croix County, Wisconsin.
~
Cf ~,
~ ~.` z
'~ ~ r4
..,r
~,,.~
~' i ST CROix
~~~
E
(SEAL)
Janet P. Stout
Exceptions to warranties: easements, restrictions, rights-of-way and covenants
of record.
Dated this day of A nr i 1 2 0 01
~e~J.9u~.~1_ \ V .CTQkJI (SEAL)
* Richard O. Stout
(SEAL)
!~
AUTHENTICATION
Signature(s)
authenticated this day of
TITLE: MEMBER STATE BAR OF WISCONSIN
KATHL FEN H. WALSH
REG.iSTER OF DEEDS
ST, f:FiCIIX CO., WI
RECEIVED FOR RECORD
04-26-2001 11:04 AM
~RRANT~Y DEED
EXFMF'T #
~,T.,~IX FEE:
COPY FEE: 2.00
~~t.FEE: 153.90
RECORDING FEE: 10.00
RAC>fiSa~,p: 1
Recording Area
Name and Return Address
r~ ~ ~~
~ 3S3 ~.~na,-~-vt~c.~-~ ;Y-.
F-{~,t~t ~^ t W~ s~ b 1~
020-1376-42-000
Parcel Identification Number (PIN)
This 1S riot homestead property.
(ls) (is not)
(SEAL)
ACKNOWLEDGMENT
State of Wisconsin,
ss.
St. Cr0].X County.
Personally -came before me this ~ 7'7l/ .day of
A p r i. l , 2 0 01 ,the above named
Richard O. Stout and Janet
P. Stout
to
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82718 SD F1' ~ ~ p
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I
W1/4 CORNER I
SECTION 14
----- ~~, eae~~la.E 425,78' I
IARC
TOP OF ALl1h~NUM CAp
I e'
~ ~ j~' B.EVATgN = 911.01'
U9CiS 1929 DATUM I
~ ~ _ . - . - .
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ACREg
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40.OS'
H.W.L.
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LOT 51
I : 2.28 AcREs
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'
• N.W.L. =828.!
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I LOT 52
4 I
I 81884 Sp FT
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